MIT Science and Engineering Program for Teachers Application Form
Completed
form should be e-mailed to: mit_sept_2006_app@att.net,
(please
rename the e-mailed form with your name)
Deadline
for submission of applications is
More detailed information about the SEPT Program can
be found at: http://web.mit.edu/scienceprogram/overview.html
NOTE: this application supercedes the application
enclosed with that package.
The applications that we select for scholarship aid
will be forwarded to MIT along with our recommendation for admittance.
A. Your
Information
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1) NAME (Last, first middle initial):
2) STREET ADDRESS:
3)
4) HOME PHONE:
5) E-MAIL ADDRESS:
6) GRADE(S) & SUBJECT(S) TAUGHT:
B. School
Information
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1) SCHOOL NAME:
2) ADDRESS:
3)
4) WORK PHONE:
5) WORK E-MAIL:
C. Your Education
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1) COLLEGE OR UNIVERSITY:
MAJOR FIELD:
DATES ATTENDED:
DEGREE AND DATE:
2) COLLEGE OR UNIVERSITY:
MAJOR
FIELD:
DATES
ATTENDED:
DEGREE
AND DATE:
3) LIST MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS:
4) LIST HONORS AND AWARDS:
5) PROFESSIONAL DEVELOPMENT COURSES PREVIOUSLY
ATTENDED:
D. General
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1) LIST EXTRACURRICULAR ACTIVITIES FOR STUDENTS THAT
YOU LEAD OR PARTICIPATE IN AND THE BENEFITS STUDENTS RECEIVE:
2) DESCRIBE YOUR TEACHING EXPERIENCES AND HOW THEY
MIGHT DISTINGUISH YOU FROM YOUR COLLEAGUES:
3) WHY IS IT IMPORTANT TO YOU TO ATTEND MIT'S SCIENCE
AND ENGINEERING PROGRAM (SEPT) FOR TEACHERS?
4) HOW DID YOU HEAR ABOUT THE PROGRAM? (IF YOU WERE REFERRED BY AN MIT CLUB MEMBER,
PLEASE GIVE THEIR NAME.)
5) PLEASE INCLUDE ANY ADDITIONAL INFORMATION YOU
THINK WOULD HELP THE COMMITTEE IN MAKING A DECISION ABOUT YOUR APPLICATION
Recommendations
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PLEASE SUPPLY THE FOLLOWING INFORMATION FOR THREE
PEOPLE WHO ARE FAMILIAR WITH YOUR TEACHING ACTIVITIES AND ASSOCIATED INTERESTS:
NAME:
ADDRESS:
PHONE NUMBER (HOME AND OFFICE):
E-MAIL ADDRESS:
NAME:
ADDRESS:
PHONE NUMBER (HOME AND OFFICE):
E-MAIL ADDRESS:
NAME:
ADDRESS:
PHONE NUMBER (HOME AND OFFICE):
E-MAIL ADDRESS:
THANK YOU
FOR YOUR INTEREST --------------------------------------------------------
The MIT Club of